The He Puna Waiora inpatient mental health unit.
Photo: RNZ
An independent review commissioned after the deaths of two patients from suspected suicide in May 2019 has identified systemic and culture issues existed at the time.
The DHB said in releasing the results today that it accepted it was responsible.
Among eight key recommendations was a need to prioritise strengthening the unit s leadership and culture.
That included a review of leadership positions, developing procedures for consistent and responsive leadership engagement, and developing an organisational cultural framework.
The second recommendation suggested ways to work towards better focus on consumers - family and whānau.